Discrimination Complaint Questionaire -Housing


Please be advised that by completing this form and returning it, you have not filed a formal complaint as required under the Fairfax County Human Rights Ordinance. Upon receipt of your completed form, commission staff will review your form and contact you to finalize the process.

1. Enter information about yourself.


First Name:*     Last Name:*  

Address:  

City:    State:    ZIP:  

Best time to call you:  

Home Phone:*    Cell Phone:    Work Phone:  

E-mail:*  

Who else has been harmed in the same way you were?



Who else can we contact if we cannot reach you?

Contact's name:    Contact's phone:  

Relationship to you:  

2. What happened to you? 

If the person discriminated against is age 18 or older, we will need that person's signature before we can proceed with this complaint. Under the Fairfax County Human Rights Ordinance only the person harmed or their legal guardian can file with the Human Rights Commission. 

  • How were you discriminated against? For example: Were you refused and opportunity to rent or buy housing? Denied a loan? Told that housing was not available in fact it was? Treated differently from other seeking housing?

  • State: briefly what happened:

3. Why do you think you are victim of housing discrimination?

Is it because of your:

Race     Religion      Disability     Color     Sex     Age (Date of birth: mm/dd/yyyy)

National Origin    Familial Status (families with children under 18)  Marital Status    Other   

For example: Were you denied housing because of your race? Were you denied a mortgage loan because of your religion? Or turned down for an apartment because you have children?

  • Briefly explain why you think your housing rights were denied and check all the factor(s) listed above that you believe apply.

4. Who do you believe discriminated against you? For example: Was it a landlord, owner, bank, real estate: agent, broker, company, and/or organization?

  • Indentify all parties who you believe discriminated against you.

1.    Address:  

2.    Address:  

3.    Address:  

4.    Address:  

5. Where did the alleged act of discrimination occur? For example: Was it a rental unit, single family home, public or assisted housing? A mobile home? Did it occur at a bank or other lending institituion?

  • Provide the address:

Address:    County: Fairfax County

City:    State:    ZIP:  

6. When did the last act of discrimination occur?

Date:   (11/22/0000)

Is the alleged discrimination continuing or ongoing?

Yes No


In Fairfax County is Unlawful to Dicriminate in Housing Based on These Factors...

  • Race
  • Color
  • National Origin
  • Religion
  • Sex
  • Familial Status (families with children under the age of 18, or who are expecting a child)
  • Handicap (if you or someone close to you has a disability)
  • Elderliness (age 55 or older)
  • Marital Status

If You Believe Your Rights Have Been Violated...

  • The Fairfax County Human Rights Commission is ready to help you file a complaint.
  • After your information is received, the Fairfax County Human Rights Specialist will contact you to discuss the concerns you have raised.

  

Please be advised that by completing this form and returning it, you have not filed a formal complaint as required under the Fairfax County Human Rights Ordinance. Upon receipt of your completed form, commission staff will review your form and contact you to finalize the process.

 


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